Quality of Life and Screening on Body Dysmorphic Disorder, Depression, Anxiety in Septorhinoplasty

OBJECTIVES

Septorhinoplasty (SRPL) can improve quality of life (QoL) in functional and aesthetical aspects of the nose. A key factor compromising postoperative satisfaction is symptoms of body dysmorphic disorder (BDD), defined by excessive concerns and distress over slight or imagined physical defects. Although a high prevalence of BDD in SRPL patients is evident, the effect of positive screening on BDD and other psychiatric disorders is understudied. It was hypothesized that patients screening positive for BDD, depression or anxiety do not show increased postoperative QoL.

METHODS

A multicenter, prospective study including 259 patients. For psychiatric evaluation, the BDD concern questionnaire-aesthetic version and the Hospital Anxiety and Depression Scale were used; for disease-specific QoL the Rhinoplasty Outcomes Evaluation (ROE) and the Functional Rhinoplasty Outcome Inventory (FROI-17).

RESULTS

In preoperative evaluation, 32.5% had a positive screening for BDD, 42.2% for increased anxiety, and 32.9% for depression. Mean QoL improved in the whole cohort (FROI total score: 54.4 ± 21.8 to 32.8 ± 23.7 and ROE: 32.3 ± 15.6 to 69.8 ± 23.1, both p < 0.001). Patients screening positive for BDD, depression or anxiety did show an increased postoperative QoL, but to a significantly lower degree and with lower pre- and postoperative QoL levels.

CONCLUSIONS

SRPL patients show a high prevalence of BDD symptoms, elevated anxiety, and depression. These subgroups show lower QoL levels and an impaired QoL increase after surgery. Rhinoplasty surgeons must be aware of the disorders and their symptoms, discuss potential concerns with the patients, and potentially refer them to a specialist.

LEVEL OF EVIDENCE

3 Laryngoscope, 134:2187-2193, 2024.

Qualitätsmanagement in der HNO – eine Standortbestimmung

Um mit der Unvollkommenheit ärztlichen Handelns umzugehen, gibt es neben gesellschaftlichen Sanktionen schon seit der Antike ethische Verhaltensvorgaben für Ärzte, die unser heutiges Verständnis von einem guten Arzt geformt haben. Mit Industrialisierung und Standardisierung wurde vor 100 Jahren in den USA der Grundstein für Qualitätsmanagement in der Medizin gelegt. In den 1950ern entstand in Japan ein umfassendes Qualitätskonzept, dass großen Einfluss auf die Medizin gewinnen sollte. Alle heutigen Zertifizierungs- und Akkreditierungsverfahren gehen aus diesen Wurzeln hervor.

Seit 15 Jahren knüpft der Gesetzgeber in Deutschland ein immer feineres Netz an Regularien, um durch externe Qualitätssicherung Mindeststandards im Gesundheitswesen zu gewährleisten. Ärztliche Institutionen der Selbstverwaltung verbessern darüber hinaus durch eigene Initiativen die Behandlungsqualität.

Qualitätsmanagement hat dauerhaft Einzug gehalten in Krankenhäuser und Praxen, zu erkennen an Risikomanagement und Patientenorientierung. Daneben gibt es eine Vielzahl an freiwilligen ärztlichen Initiativen zur Qualitätssicherung, z. B. die Leitlinien der ärztlichen Fachgesellschaften.

Per Umfrage wurde die Implementation eines Qualitätsmanagementsystems in deutschen HNO-Kliniken und -Praxen evaluiert und mit dem Bundesdurchschnitt verglichen. Es fand sich überwiegend eine umfassendere Umsetzung als in den Vergleichsgruppen.

Die aktuellen Herausforderungen an Kliniken und Praxen sind erheblich und haben Auswirkungen auf das Qualitätsniveau. Unterfinanzierung, Personalmangel und gesellschaftliche Veränderungen sind hier genauso relevant wie Auswirkungen des wissenschaftlichen Fortschritts.

Um Qualitätsmanagement zukünftig umfassend zu implementieren, sind kluge politische Weichenstellungen und Ressourcen entscheidend – das Konzept an sich hat sich längst durchgesetzt.

[Chinese medicine and constructivism-a new way in psychotherapy]

BACKGROUND

The background of this study is twofold: basic methodological differences between Western Biomedicine and Classical Chinese Medicine (CCM) and obvious parallels between the methodology of psychotherapy and CCM.

OBJECTIVES

Drawing on available investigations on the methodology of CCM, the analysis of structural parallels between CCM and Western psychotherapy tries to enrich the methodological self-conception of psychotherapy in order to provide impulses for the new approaches to psychotherapeutic practice.

METHODS

The reciprocal interpretation of CCM about the patient's state draws on a language of metaphors. These metaphors "mediate" between the various positions of the universal interdependency and the human being, who is able to understand the language. The constructive realistic methodology in general and the epistemological method of "alienation" in particular, provide an instrument for the decodification of these metaphors.

RESULTS

In the context of CCM, the process dynamics of mental healing are based on hermeneutical principals. Every operation carried out by the CCM therapist is not organ medical in nature but a purely semantic form. These semantic operations aim to provide a meaningful integration of problematical behavior (in terms of meaning) into metaphorically logical structures in order to stimulate a coherent self-understanding of the suffering individual, which is associated with healing effects. In this context, it is crucial for CCM that there is no conceptual division between body and soul with respect to the therapy. This enables a completely different comprehensive treatment of mental problems than biomedicine is able to offer, due to its methodological presuppositions.

Patients Screening Positive for Body Dysmorphic Disorder Show No Significant Health-Related Quality of Life Gain after Functional Septorhinoplasty at a Tertiary Referral Center

Body dysmorphic disorder (BDD) is a psychiatric disorder defined by an excessive concern about one's physical appearance, especially regarding slight or imagined abnormities of the body. This study was conducted to compare postoperative quality of life (QOL) changes after primary septorhinoplasty among patients screening positive and those screening negative for BDD. Two common instruments for the screening of BDD were used namely the Dysmorphic Concern Questionnaire (DCQ) and the BDD Concern Questionnaire (BDDQ). For the determination of QOL changes, three validated screening instruments were used. The Functional Rhinoplasty Outcome Inventory (FROI-17) and the Rhinoplasty Outcomes Evaluation (ROE) were used as disease-specific instruments and the Short Form 36 Health Survey (SF-36) was used as a general instrument. All patients completed the FROI-17, the ROE, and the SF-36 preoperatively and 60 months postoperatively. The BDD questionnaires were singularly obtained 60 months after surgery. The authors identified 9.8% of our patients with a possible BDD diagnosis. The patients screening positive for BDD showed significantly lower ROE scores postoperatively, compared with those screening negative for BDD. QOL gains detected by the disease-specific instruments (ROE and FROI-17) were only significant in the non-BDD group. No significant QOL gains were detectable with the FROI-17, the ROE, and the SF-36 in the BDD group. In patients screening negative for BDD, QOL, as measured with the SF-36, improved significantly in five categories: physical functioning, role-functioning physical, bodily pain, general health, and social functioning. Patients screening positive for BDD did not improve in any categories of the general SF-36 questionnaire. Instead, their score in the "mental health" category was significantly lower 5 years after their surgery compared with preoperatively. Patients retrospectively screening positive for BDD in our cohort did not improve in QOL postoperatively. Alternative nonsurgical treatments such as cognitive behavioral treatment and/or selective serotonin reuptake inhibitors have been reported to be effective and should be considered as the treatment of choice. Some studies suggest that a smaller subgroup of BDD patients may benefit from functional rhinoplasty. Further research and larger long-term prospective outcome studies are needed to understand the influence of BDD symptoms on postoperative satisfaction and QOL changes after septorhinoplasty.

Long-term quality of life changes after primary septorhinoplasty

PURPOSE

Health-related quality of life measurements are gaining in importance in clinical medicine. Little is known about the long-term quality of life changes after septorhinoplasty. This study was designed to analyse the long-term quality of life impacts of septorhinoplasty, using disease-specific instruments-rhinoplasty outcome evaluation (ROE) and Functional Rhinoplasty Outcome Inventory-17 (FROI-17); as well as a generic instrument-Short-Form 36 Health Survey (SF-36).

METHODS

Patients completed the FROI-17, the ROE and the SF-36 preoperatively and at 12 and 60 months postoperatively. General demographic and clinical information (age, gender, allergies, medication, medical and surgical history) were collected from all patients.

RESULTS

We report a significant increase in disease-specific QOL after primary septorhinoplasty (as measured with the ROE & FROI-17) and in two scales of the SF-36 generic instrument (role-functioning physical and mental health) 1 year after surgery. Our patients showed further significant increase in disease-specific QOL (FROI-17) after their primary septorhinoplasty (1 year vs. 5 years postoperatively). SF-36 results showed significant improvements 5 years postoperatively (compared to preoperative scores) in six out of eight scales (physical functioning, role-functioning physical, bodily pain, vitality, social functioning and mental health).

CONCLUSION

Septorhinoplasty can improve disease-specific and non-disease-specific QOL in the short- and long-term postoperative period. These improvements remain measurable 5 years after surgery.

Development and validation of the Functional Rhinoplasty Outcome Inventory 17 (FROI-17)

STATEMENT OF PROBLEM

Quality of life aspects become more and more important in all fields of medicine. There is a lack of such instruments for septorhinoplasty that cover sufficiently both functional and aesthetic aspects.

METHODOLOGY

In Phase 1, a group of experts identified 22 questions that represent the symptoms of patients with nasal deformities, which undergo a functional and aesthetic nasal surgery. Forty-one patients filled out the questionnaires before septorhinoplasty. The item assessment and item reduction was performed by a sequential statistical analysis, which included a single item analysis, an assessment of internal consistency, construct validity, the divergence validity and a factor analysis. The resulting 17-item questionnaire was used in a prospective validation study (Phase 2) in which 103 patients were enrolled. Statistical analysis included testing of validity, reliability and responsiveness.

RESULTS

In Phase 2 data analysis revealed a good internal consistency and significant test-retest reliability. A literature survey confirmed that the relevant items were included in the questionnaire. We found significant item-score-correlations. Furthermore, the existence of concurrent validity was confirmed. Standardized Response Mean (SRM) as a measure for sensitivity to change indicated moderate to large effects.

CONCLUSION

FROI-17 is a valid quality of life instrument for use in septorhinoplasty patients. The instrument is now available for prospective data collection in future septorhinoplasty outcome studies.

Quality of life after primary septorhinoplasty in deviated- and non-deviated nose measured with ROE, FROI-17 and SF-36

BACKGROUND

Quality of life measurements are gaining in importance. The present study was conducted with the aim to compare patient satisfaction after septorhinoplasty according to their preoperative nasal deformity.

METHODS

The patients completed two disease-specific questionnaires before their surgery: the Functional Rhinoplasty Outcome Inventory (FROI-17), the Rhinoplasty Outcome Evaluation (ROE) and as a general instrument, the Short Form 36 Health Survey (SF-36). The second measurement was taken during an outpatient examination 12 months after their primary septorhinoplasty. Patients were grouped in nasal axis deviation (NAD), nasal hump deformity (NHD) and NAD plus NHD. Additionally the patients with preoperative NAD and NAD+NHD were combined as deviated nose and compared to the non-deviation group.

RESULTS

One hundred and two patients (51 male and 51 female) underwent primary septorhinoplasty. The ROE- and the FROI-17 overall score including all three subgroups showed significant postoperative improvements. Regarding the SF-36, the postoperative score improved significantly only in two scales (role-functioning physical and mental health). Looking at the the different QoL questionnaires, there were significant postoperative differences in regards to deviated versus non-deviated nose in the FROI-17 overall- and FROI-17 subscores (nasal and general symptoms) and in three scales of the SF-36 (vitality, social functioning, role-functioning emotional), showing a greater postoperative satisfaction in the deviated-nose patient.

CONCLUSION

Patients with and without nasal deviation showed improved QoL after their surgery, as measured with the ROE, the FROI-17 and the SF-36. The patients with a nasal deviation showed a significantly better outcome, as measured with the FROI-17, in comparison with the non-deviated group.

Quality of life after primary septorhinoplasty in deviated- and non-deviated nose measured with ROE, FROI-17 and SF-36

BACKGROUND

Quality of life measurements are gaining in importance. The present study was conducted with the aim to compare patient satisfaction after septorhinoplasty according to their preoperative nasal deformity.

METHODS

The patients completed two disease-specific questionnaires before their surgery: the Functional Rhinoplasty Outcome Inventory (FROI-17), the Rhinoplasty Outcome Evaluation (ROE) and as a general instrument, the Short Form 36 Health Survey (SF-36). The second measurement was taken during an outpatient examination 12 months after their primary septorhinoplasty. Patients were grouped in nasal axis deviation (NAD), nasal hump deformity (NHD) and NAD plus NHD. Additionally the patients with preoperative NAD and NAD+NHD were combined as deviated nose and compared to the non-deviation group.

RESULTS

One hundred and two patients (51 male and 51 female) underwent primary septorhinoplasty. The ROE- and the FROI-17 overall score including all three subgroups showed significant postoperative improvements. Regarding the SF-36, the postoperative score improved significantly only in two scales (role-functioning physical and mental health). Looking at the the different QoL questionnaires, there were significant postoperative differences in regards to deviated versus non-deviated nose in the FROI-17 overall- and FROI-17 subscores (nasal and general symptoms) and in three scales of the SF-36 (vitality, social functioning, role-functioning emotional), showing a greater postoperative satisfaction in the deviated-nose patient.

CONCLUSION

Patients with and without nasal deviation showed improved QoL after their surgery, as measured with the ROE, the FROI-17 and the SF-36. The patients with a nasal deviation showed a significantly better outcome, as measured with the FROI-17, in comparison with the non-deviated group.

Quality of life after septorhinoplasty measured with the Functional Rhinoplasty Outcome Inventory 17 (FROI-17)

BACKGROUND

Quality of life measurements in septorhinoplasty patients so far have taken place only to a small extent. The aim of the present study was a prospective measurement of disease-specific quality of life with a newly developed and validated instrument, the Functional Rhinoplasty Outcome Inventory 17 (FROI-17).

METHODS

The patients completed the FROI-17 and the Rhinoplasty Outcome Evaluation (ROE) as disease-specific instruments preoperatively as well as 12 months postoperatively. As a general instrument, the Short Form 36 Health Survey (SF-36) was used. Furthermore, additional general questions were answered at both time points.

RESULTS

Out of the 103 patients, 69 patients (32 men, 37 women) responded after 12 months (response rate 67%). Thirteen patients (18%) were not satisfied with the result of surgery. However, all scales of FROI-17 and also ROE showed a significant postoperative improvement of subjective assessments by the patients. In the SF-36, this was true in 2 out of 8 scales (mental health and role-functioning physical). Furthermore, we found significant correlations between the FROI-17 and the SF-36 scales but not between the ROE and the SF-36 scales.

CONCLUSION

The disease-specific quality of life was significantly improved by septorhinoplasty. FROI-17 scales detect more functional aspects compared with the ROE thus establishing significant correlations with general quality of life measured by SF-36. The application of both FROI-17 and ROE in future clinical trials in septorhinoplasty patients is recommended.

Quality of life after septorhinoplasty measured with the Functional Rhinoplasty Outcome Inventory 17 (FROI-17)

Background: Quality of life measurements in septorhinoplasty patients so far have taken place only to a small extent. The aim of the present study was a prospective measurement of disease-specific quality of life with a newly developed and validated instrument, the Functional Rhinoplasty Outcome Inventory 17 (FROI-17). Methods: The patients completed the FROI-17 and the Rhinoplasty Outcome Evaluation (ROE) as disease-specific instruments preoperatively as well as 12 months postoperatively. As a general instrument, the Short Form 36 Health Survey (SF-36) was used. Furthermore, additional general questions were answered at both time points. Results: Out of the 103 patients, 69 patients (32 men, 37 women) responded after 12 months (response rate 67%). Thirteen patients (18%) were not satisfied with the result of surgery. However, all scales of FROI-17 and also ROE showed a significant postoperative improvement of subjective assessments by the patients. In the SF-36, this was true in 2 out of 8 scales (mental health and role-functioning physical). Furthermore, we found significant correlations between the FROI-17 and the SF-36 scales but not between the ROE and the SF-36 scales. Conclusion: The disease-specific quality of life was significantly improved by septorhinoplasty. FROI-17 scales detect more functional aspects compared with the ROE thus establishing significant correlations with general quality of life measured by SF-36. The application of both FROI-17 and ROE in future clinical trials in septorhinoplasty patients is recommended.

Development and validation of the Functional Rhinoplasty Outcome Inventory 17 (FROI-17)

STATEMENT OF PROBLEM

Quality of life aspects become more and more important in all fields of medicine. There is a lack of such instruments for septorhinoplasty that cover sufficiently both functional and aesthetic aspects.

METHODOLOGY

In Phase 1, a group of experts identified 22 questions that represent the symptoms of patients with nasal deformities, which undergo a functional and aesthetic nasal surgery. Forty-one patients filled out the questionnaires before septorhinoplasty. The item assessment and item reduction was performed by a sequential statistical analysis, which included a single item analysis, an assessment of internal consistency, construct validity, the divergence validity and a factor analysis. The resulting 17-item questionnaire was used in a prospective validation study (Phase 2) in which 103 patients were enrolled. Statistical analysis included testing of validity, reliability and responsiveness.

RESULTS

In Phase 2 data analysis revealed a good internal consistency and significant test-retest reliability. A literature survey confirmed that the relevant items were included in the questionnaire. We found significant item-score-correlations. Furthermore, the existence of concurrent validity was confirmed. Standardized Response Mean (SRM) as a measure for sensitivity to change indicated moderate to large effects.

CONCLUSION

FROI-17 is a valid quality of life instrument for use in septorhinoplasty patients. The instrument is now available for prospective data collection in future septorhinoplasty outcome studies.

Long-term results of a prospective multicenter phase II study to preserve the larynx function using concomitant boost radiochemotherapy with Carboplatin

PURPOSE

This prospective phase II study was undertaken to assess the feasibility of a larynx preservation protocol with simultaneous radiochemotherapy.

PATIENTS AND METHODS

Between 3/1998 and 10/2000, 42 patients with moderately advanced cancer of the larynx (n=25) and hypopharynx (n=17) eligible for total laryngectomy (LE) were treated in a prospective larynx preservation study. The study protocol scheduled 66Gy in 5 weeks using a concomitant boost technique and 70mg/m(2) Carboplatin on days 1-5 in weeks 1 and 5.

RESULTS

The median follow-up time of the censored study patients was 41 months (9-95 months). The 5-year overall survival was 0.66 (95% CI 0.48-0.84), the 5-year laryngectomy-free survival 0.60 (95% CI 0.42-0.78), and the laryngeal preservation rate at 5 years 0.67 (95% CI 0.49-0.85). Cox multivariate regression analysis showed the total tumor volume to be the only statistically significant factor on locoregional failure-free survival. Six of 23 tumor-free long-term survivors received a tracheotomy because of late laryngeal toxicity associated with dysphagia 30-79 months after radiochemotherapy.

CONCLUSIONS

Due to the late laryngeal toxicity observed the value of this regimen for larynx preservation is limited.

The accuracy of the modified Evans blue dye test in detecting aspiration in head and neck cancer patients

The purpose of this study was to determine sensitivity and specificity of the modified Evans blue dye test (MEBDT) in tracheostomised patients after treatment of head and neck squamous cell carcinoma (HNSCC). This was a prospective study with 30 consecutive patients. All individuals underwent a MEBDT and a subsequent fiberoptic endoscopic evaluation of swallowing (FEES) immediately after the MEBDT for reconsidering the validity of the MEBDT. Aspiration was present in 20 patients documented by MEBDT and FEES. One patient was judged to aspirate by FEES but not by MEBDT (1 false-negative result). Nine patients showed no aspiration either by MEBDT or by FEES. The sensitivity of the MEBDT protocol in predicting aspiration among individuals in our cohort was 95.24%, the specificity 100%, respectively. The results of the current investigation suggest that the MEBDT is much more sensitive in tracheostomised HNSCC patients than in tracheostomised neurological patients. The MEBDT for tracheostomised HNSCC patients offers a quick and reliable method to identify aspiration risk in cases of severe dysphagia.

Leakage of Fluid in Different Types of Tracheal Tubes

The aim of this study was to evaluate leakage of liquids, i.e., water and saliva, past low-pressure cuffs of tracheostomy tubes. Three different types of tracheostomy tubes, TRACOE vario (TRACOE Medical GmbH, Germany), Rüsch Ultra-Tracheoflex (Rüsch GmbH, Germany), and Portex Blue Line Ultra (Smiths Medical, UK) were tested in isolated pig tracheas. Sixty samples (10 tubes each of 7- and 8-mm inner diameter of each type) were used. Four different experiments were devised: type 1 (water and artificial ventilation), type 2 (water and no artificial ventilation), type 3 (saliva and artificial ventilation), and type 4 (saliva and no artificial ventilation). Six milliliters of water or artificial saliva were infused over the cuff and the volume of fluid that leaked past the cuff was measured after 5, 10, and 15 min. Intracuff pressure was also measured three times. The saliva experiments resulted in less leakage than the water experiments. Leakage after treatment with water or artificial saliva is higher without artificial ventilation than with ventilation. The amount of leakage among the tubes with respect to manufacturer showed statistically significant results. However, there were no differences among tracheostomy tubes with respect to internal diameter.

Backyard swimming pool safety inspections: a comparison of management approaches and compliance levels in three local government areas in NSW

ISSUE ADDRESSED

Since 1992, swimming pool fencing has been a legislative requirement in New South Wales (NSW), yet compliance with the NSW Swimming Pool Act is mixed. Local councils are responsible for the enforcement of the act. However, their approach to enforcement and the management of backyard swimming pool safety inspections is varied.

METHODS

A random sample of backyard swimming pools was inspected in Council A and existing compliance data for pools in two other councils (B and C) were obtained. Pool owners in Council A were surveyed regarding their attitudes to pool fencing and inspections. Semi-structured interviews were conducted with council employees.

RESULTS

Pool compliance rates across the three council areas varied. In Councils A and C, 51% and 54% of pools, respectively, were found to be non-compliant at the first inspection. Following re-inspection in Council A of 227 pools, a further 125 pools reached compliance. In Council B, 97% of the inspected pools were compliant.

CONCLUSIONS

This study provides evidence of poor backyard swimming pool safety compliance where local government inspection activity is minimal or non-existent.

[Evaluation of aspiration protective-covered tracheal cannulas]

BACKGROUND

The aim of the study was to evaluate leakage of liquids in terms of water and artificially produced saliva past low-pressure cuffs of tracheal tubes.

METHODS

Three different types of tracheal tubes, TRACOE vario, Rüsch Ultra-Tracheoflex, and Portex Blue Line Ultra, were tested in isolated pig tracheas by infusing 6 ml of water or artificially produced saliva over the cuff and measuring the volume of fluid leaking past the cuff after 5, 10, and 15 min.

RESULTS

The leakage in the saliva experiments was significantly lower than in the water experiments (p < 0.05). The amount of leakage between the three different types of tubes showed statistically significant (p < 0.05) results. There was no statistically significant difference between tracheal tubes of 7 and 8 mm internal diameter.

CONCLUSION

The present laboratory findings suggest that the three tracheal tubes studied will not guard against aspiration of water but they will prevent the leakage of artificial saliva to a great extent.

[Health aspects of diving in ENT medicine. Part I: Diving associated diseases]

There has been a steady increase in the number of recreational scuba divers in the last years, with a growing number of diving associated diseases involving ENT medicine. Disorders of the ears, sinuses and pharynx are those most common in divers. In particular, external otitis and barotrauma of the middle ear are commonly treated by every ENT specialist. They usually do not lead to any permanent complaints. Incidents involving the cochleovestibular system are less common, but can result in deafness, vertigo and tinnitus, and therefore have to be treated appropriately. To treat diving medical disorders, the physician has to have some basic understanding of the physical laws that lead to diving incidents. This article will inform the reader of the forces that are encountered by divers, and then give details of the treatment of acute ENT diseases which result from diving incidents.

Prognostic impact of EBV-related LMP-1, histologic type, and environmental factors in nasopharyngeal carcinoma in a German population

INTRODUCTION

This retrospective study addressed the possible involvement of latent Epstein-Barr virus (EBV) infection, in particular LMP-1 expression, and further exogenous factors, i.e. tobacco, alcohol and occupational hazardous substances, in nasopharyngeal carcinoma (NPC) in a German population.

PATIENTS AND METHODS

From 1980 to 2000, 44 patients suffering from histologically confirmed NPC were entered into the study. 33 specimens were available for immunostaining (IHC) to analyze LMP-1 expression. Information about environmental exposures were obtained employing a detailed standardized questionnaire.

RESULTS

Outcome of patients with squamous cell NPC (SC-NPC) was significant worse than that of those with non-keratinizing NPC (NK-NPC). Age and tumor size correlated with response to therapy. The group with negative conventional LMP-1 staining showed better overall survival after 5 years compared to the group with positive or marginally positive LMP-1 detection (not significant). Nevertheless, after staining by tyramid-augmented IHC (TSA-IHC), nearly all specimens with negative LMP-1-staining in conventional IHC were found to be clearly positive. All patients with SC-NPC were smokers. The distribution of smokers and non-smokers in the group of NK-NPC was balanced. Comparable to the tobacco observation, there was also a correlation between high alcohol consumption and SC-NPC.

CONCLUSION

Prognosis of NPC is mainly dependent on histologic type. Prognostic impact of LMP-1 is still unclear since LMP-1 was detected in all specimens using TSA-IHC. Therefore, TSA-IHC-LMP-1 detection might be interesting for diagnostic specification and development of new therapeutic strategies in NPC.

Ex vivo responsiveness of head and neck squamous cell carcinoma to glufosfamide, a novel alkylating agent

BACKGROUND

Glufosfamide is a novel alkylating agent in which the active metabolite of isophosphoramide mustard is glycosidically linked to beta-D-glucose. Targeting the elevated glucose uptake of tumor cells expressing the SAAT1 glucose transporter, glufosfamide represents an attractive new drug for cancer chemotherapy. The present study investigates the ex vivo responsiveness of Head and Neck Squamous Cell Carcinoma (HNSCC) specimens to glufosfamide.

PATIENTS AND METHODS

Twenty-one unselected HNSCC specimens were investigated using a novel ex vivo colony formation assay to determine the epithelial drug response. The individual responsiveness to glufosfamide and to cis-platinum was determined.

RESULTS

Five out of 21 evaluable HNSCC specimens were sensitive to glufosfamide. There was a tendency for glufosfamide sensitivity in platinum-resistant specimens and vice versa.

CONCLUSION

The effectiveness of glufosfamide observed in the present ex vivo study suggests at least an equipotentiality of glufosfamide in comparison to cis-platinum. The potential clinical usefulness of glufosfamide in HNSCC warrants further evaluation.

[Health aspects of diving in ENT medicine. Part II: Diving fitness]

Diving has become increasingly popular. With the growing number of patients who want to dive, there is an increasing number of divers who require their regular medical examination. As ENT problems are the most common disorders in divers, otorhinolaryngologists regularly have to assess the diver's fitness. It should be noted that an ENT examination does not certify complete fitness to dive! Diving can be resumed 3 months after middle ear surgery, especially after tympanoplastic type I, II and III with insertion of a PORP, when there is regular middle ear ventilation without atrophic scars of the tympanic membrane. Even after stapes surgery, diving can be resumed when there are no signs of vestibular irritation during a provocation test. By 3 months after sinus surgery, the diver should perform a test dive under supervision before fitness to dive can be certified. After inner ear barotrauma, the diver remains fit to dive depending on his hearing ability in the involved ear. After inner ear decompression illness, one should look for a vascular right-to-left shunt before diving can be resumed. These and many more aspects are discussed in this article on how to determine whether a diver with ENT problems is fit to dive.

Long-term outcome after Griggs tracheostomy

OBJECTIVE

The purpose of this study was to evaluate laryngotracheal stenoses in the long-term outcome after percutaneous tracheostomy.

METHODS

Between 1997 and 2000, 162 patients were tracheostomized during their postoperative stay at the intensive care unit of the Department of Cardiac Surgery, University of Heidelberg. Thirty-eight of 80 long-term surviving patients (mean follow-up: 22 months, range: 7-50 months) gave their informed consent to follow-up laryngotracheoscopy. By using this technique, we localized the tracheostomy site, evaluated the laryngotracheal morphology, and quantified laryngotracheal stenosis planimetrically.

RESULTS

Clinically relevant stenoses were found in one patient. Another patient had undergone surgical revision of the percutaneous dilatational tracheostomy (PDT) prior to our examination. The endoscopic examination revealed that 89.5% (34/38) of the patients exhibited tracheal stenosis, less than 25% without clinical symptoms. Despite endoscopic guidance during PDT, the location of the puncture site was found to vary greatly. Cricoidal lesions were identified in 15 patients. In only 12 patients (31.6%), the PDT had been placed at the optimal location between the first and the second tracheal ring. In these patients, we found the lowest rate of tracheal stenosis in tracheotomies without fractured tracheal rings.

CONCLUSION

Since clinically relevant tracheal stenosis has been found to depend mainly on the puncture site of the PDT and tracheal fractures during PDT, we want to emphasize the importance of adequate endoscopic guidance during and the careful performance of the PDT. Further follow-up studies are necessary to improve and ensure the quality of PDT techniques.

Laryngotracheoscopic findings in long-term follow-up after Griggs tracheostomy

OBJECTIVE

Analysis of laryngotracheoscopic findings of the upper airway tract following percutaneous tracheostomy using the technique according to Griggs.

DESIGN

Retrospective cohort study

PATIENTS

Nineteen of 32 long-term surviving patients (mean follow-up duration, 17 months; range, 11 to 23 months) underwent a modified Griggs tracheostomy during their stay in the ICU following cardiothoracic surgery.

INTERVENTIONS

Nineteen patients gave their informed consent for laryngotracheoscopy to localize and assess the percutaneous dilatational tracheostomy (PDT) puncture site, to evaluate the laryngotracheal morphology, and to quantify tracheal stenosis if present. In addition, specific symptoms of the upper airway tract were evaluated.

RESULTS

At the time of examination, no clinically relevant cases of stenoses were found, although one patient had undergone surgical revision of the PDT for extensive granulation prior to our examination. The endoscopic examination revealed that 12 of 19 patients (63%) had tracheal stenoses > 10%, and 2 patients had tracheal stenoses > 25%. In 7 of 19 patients (32%), the cricoid cartilage was affected by the PDT site. Despite endoscopic guidance during PDT, the location of the puncture site was found to vary greatly.

CONCLUSION

In contrast to recent reports on the long-term outcome after Griggs PDT, we found tracheal stenoses > 10% in 63% of our patients. The grade of stenosis depended mainly on the puncture site of the PDT. Based on these results, we would emphasize the importance of adequate endoscopic guidance during PDT. Further studies are required in order to clarify the risk of long-term complications arising after PDT using the technique of Griggs.

[Antibiotic impregnation of cartilage implants: diffusion kinetics of fluoroquinolones]

BACKGROUND

Antibiotic impregnation of cartilage implants may reduce the risk of bacterial infection and subsequent absorption. The aim of this study was to investigate the penetration kinetics of two quinolone antibiotics into fresh cartilage and the concentrations in the core of lyophilized cartilage after rehydration.

METHODS

Fresh human costal cartilage was impregnated with ofloxacin and ciprofloxacin (2 mg/ml) for 2, 15 and 90 min. Concentrations were measured in 6 levels (0.5 mm each) from the surface to 3 mm beneath the surface with high performance liquid chromatography (HPLC). Lyophilized human costal cartilage was rehydrated in ofloxacine and ciprofloxacine solutions (2 mg/ml, 0.2 mg/ml and 0.02 mg/ml) for 18 hours and concentrations in the core of the rib segment were measured.

RESULTS

Quinolone antibiotics penetrate into cartilage by free diffusion. We found no evidence of significant binding to cartilage. After 2 and 15 min of impregnation, concentrations above the minimal inhibitory concentration (MIC90) for pseudomonas species are found from 0-0.5 mm below the surface of fresh cartilage. After 90 min concentrations above the MIC90 were found 1.0-1.5 mm below surface of the implant. In lyophilized rib grafts which were rehydrated in 1/10 diluted intravenous solutions (0.2 mg/ml), concentrations in the core of the specimen were above MIC90. Differences between the penetration characteristics of ofloxacine and ciprofloxacine were minor.

CONCLUSION

Intraoperative impregnation of cartilage implants with ofloxacin or ciprofloxacin probably offers only short-term protection against bacterial infection. Rehydrated rib grafts, however, contain high quinolone concentrations which may be effective even in infected implant beds for several hours.

[An aberrant course of the internal carotid artery through the middle ear]

The presence of the internal carotid artery in the middle ear is a rare but known vascular anomaly. A blue-reddish mass behind the tympanic membrane, hearing loss and a tinnitus that is synchronous with the pulse are the typical symptoms and should lead to a correct diagnosis. The diagnostic procedure includes high resolution CT scans with or without contrast or MRI. Possible methods of therapy include embolization, stent implantation or balloon occlusion of the internal carotid artery but are seldom indicated clinically because of the high rate of side-effects. However, regular followup examinations must be performed.

[The potential uses and limitations of the flexible laryngoscopy under local anesthesia in clinical practice]

Microsurgery of the larynx is commonly performed as direct laryngoscopy (DL) under general anesthesia. An alternative in selected cases is flexible laryngoscopy (FSL) under local anesthesia. We used a flexible laryngoscope that contained an additional working tunnel (Olympus ENF Type T3). Local anaesthesia of the larynx was achieved with 1% oxybuprocaine-HCl. Tissue samples were taken under endoscopic view and control. Twenty-five patients were studied and had benign lesions of the larynx or were being followed after treatment for cancer. The examination was tolerated well by all patients. The handling of the endoscope allowed precise targeting and sample taking. Due to the 2.2 mm diameter of the forceps the sizes of the biopsies were also limited. However, nearly all of the biopsies taken allowed sufficient histological examination. The advantage of the FSL was its simplicity and the minor inconvenience for patients. Although true histological results of suspect findings are possible, limitations in examining the hypopharynx prevent true staging of cancer patients. In general, FCL is a worth-while complement to DL.

[Exophytic papillomatous space-occupying lesions of the larynx as a rare manifestation of candidiasis. Diagnostic and therapeutic consequences]

Laryngeal candidiasis is very rare in the absence of other more proximal diseases in the aerodigestive tract. The lesion shows pseudoepitheliomatous hyperplasia or acanthosis and, given its rarity, may be confused with cancer. In the present paper we report on a 56-year-old male patient who presented with hoarseness. Physical examination of the larynx revealed a hyperplastic lesion involving both vocal cords. The clinical aspect and the risk factor profile of the patient (ten bottles of beer and 40 cigarettes per day) generated the clinical diagnosis of laryngeal cancer. A biopsy was taken. The histopathological examination of the specimen excluded a squamous cell carcinoma; however, it could not provide a clear diagnosis. Laryngeal papillomatosis and tuberculosis, which had been suspected, could be excluded. As the lesion progressed, further biopsies led to the diagnosis of candidiasis. Systemic antimycotic treatment with fluconazol and amphotericin caused a complete remission.

Is monocular perception of depth through the rigid endoscope a disadvantage compared to binocular vision through the operating microscope in paranasal sinus surgery?

Vision through the endoscope is strictly monocular. Perception of depth (stereopsis) during ethmoid surgery through the operating microscope would be expected to be superior due to binocular view. To investigate whether monocularity of the endoscope is a disadvantage in paranasal sinus surgery, we compared stereoacuity in a model of the nasal cavity using a headlamp, an operating microscope, and a 0 degree-Hopkins-endoscope. Twenty volunteers were asked to touch defined points in a spatial model of the nasal cavity. Due to the configuration of the model, which allowed binocular vision of all contact points with headlamp, performance was significantly better than with optical instruments. Manipulations were performed faster with the endoscope than with the microscope. Under microscopic guidance more faults in point sequence were made than with the endoscope. Various monocular phenomena obviously allow sufficient spatial orientation through the endoscope, so that monocularity of the endoscope appears not to be a disadvantage for quick and safe manipulations during functional endoscopic sinus surgery.

[Rest-activity cycle in man]

An actigraph (ZAK company) is a small device that can be worn on the wrist like a watch. We carried out a study to compare sleep efficiency and total sleep time as determined by actigraphy and polysomnography. The number of body movements per minute is a density function. The integrated function shows a virtually constant gradient in the wake state and a different constant gradient during sleep. The body movement density function per hour provides a useful threshold for correctly differentiating between wake and sleep states. This threshold is defined as the minimum between the two maxima of the bimodal logarithmic body movement density distribution. In the second step we computed a rank scale of the different gradients and approximated the integrated function for every scale element using linear graphs. The points of intersection of the straight lines define the time points for sleep onset and end of sleep. Sleep efficiency is given by SE = 100 (TST-sleep interruption time)/TST. Total sleep time is the interval between sleep onset and end of sleep. Actigraphy is a suitable semi-objective method for estimating sleep efficiency and total sleep time, and--for cost reasons--should be used for screening before approaching a sleep laboratory. Actigraphy carried out over several days shows only small differences in comparison with polysomnography. The estimation of parameters is more accurate the longer the patient wears the actigraph, and a minimum of five days is recommended. Spectral analysis of the intregrated body movement density provides important information for detecting subclinical sleep disorders.

[Detection of rapid eye movement with rapidly adapting neuronal fuzzy systems in imprecise REM syntax]

Both living beings and artificial neuronal networks are capable of 'learning' and behavioural adaptation. But also the fuzzy program designed to detect rapid eye movements (REM) during sleep and described here, can be provided with a self-learning option that provides important information about REM sleep. The algorithm computes REM on the basis of horizontal and vertical EOG. EEG, EMG and actiography signals are employed to optimize the method and eliminate artefacts. In a second step, the fuzzy system learns to detect REM with the aid of a sample data set and a minimal set of syntax rules. From sample data and the actions and reactions of visual scorers, the program extracts additional rules and information, which are then used to build a complete fuzzy structure. Thereafter, the REM detection program optimizes the fuzzy logic structure, independently of visual monitoring, on its own. A direct comparison of the results of the algorithm in a 10-night analysis with those of two experienced visual scorers revealed a better than 95% agreement. Re-analysis with the algorithm showed a 100% concurrence. Complete visual measurement of the eye movements occurring in a single night requires several hours; this compares with only 15 minutes required by the algorithm.

[How good is spatial orientation with rigid endoscopic optics? Study of micromanipulation in the nasal cavity]

Rigid endoscopes are used as an alternative to the operating microscope for visual control during paranasal sinus surgery. Since the view through the endoscope is monocular, perception of depth (stereopsis) through the operating microscope must be expected to be superior due to the binocular view afforded. To investigate whether monocular visualization through an endoscope is a disadvantage in paranasal sinus surgery, we compared stereoacuity in a model of the nasal cavity, using a head lamp, an operating microscope and a 0 degree Hopkin's endoscope. Twenty volunteers had to touch defined points in a spatial model of the nasal cavity. Under binocular vision with a head lamp, performance was significantly better than with the microscope or the endoscope. Manipulations were performed with the same speed under microscopic and endoscopic control, although under microscopic guidance more faults in point sequence were made than with the endoscope. Various monocular phenomena seem to allow sufficient spatial orientation through the endoscope, so that monocular visualization does not appear to be a disadvantage for quick and safe manipulations during functional endoscopic sinus surgery.

[Color-coded sleep EEG power density spectra]

The colour-coded representation of transformed sleep EEG power density spectra makes it possible to demonstrate changes in sleep architecture. With the aid of this method, spectral changes in physical units can be shown. The present study also shows that sleep is a continuous process which, for clinical interpretation, urgently needs to be processed with this in mind, in particular for the investigation of the effects of psychopharmaceuticals. The method is derived mathematically, and illustrated by convincing examples. It is to be hoped that the method will be accepted without delay and its use spread rapidly.

[The coexpression of keratin and vimentin in untreated squamous cell carcinoma of the ENT tract]

Forty-four untreated squamous-cell carcinomas of the upper aerodigestive tract were examined immunohistochemically with antibodies against keratin and vimentin. Surprisingly, in 18% of cases, a coexpression of both intermediate filaments was found both in undifferentiated carcinomas and in highly differentiated carcinomas, where it was only possible to observe this phenomenon in the basal cell layer. The tumor-biological relevance of these findings must be the subject of further investigations.

Coexpression of intermediate filaments in squamous cell carcinomas of upper aerodigestive tract before and after radiation and chemotherapy

Frozen sections of 48 squamous cell carcinomas and seven undifferentiated carcinomas of the upper aerodigestive tract were investigated immunohistochemically with monoclonal antibodies specific for keratin, vimentin, desmin, neurofilaments, and glial fibrillary acidic proteins. In nine squamous cell carcinomas (19%) and six undifferentiated carcinomas (86%) obtained before treatment coexpression of keratin and vimentin was detected in some tumor cells by double immunofluorescence studies. Nine squamous cell carcinomas expressed neurofilaments in scattered tumor cells. Coexpression of vimentin or neurofilaments was seen especially in the peripheral cell layer of the tumor nests and did not seem to correlate with the degree of differentiation. Three undifferentiated carcinomas additionally expressed desmin, and one tumor contained neurofilaments. Glial fibrillary acidic proteins were not detected. Increased coexpression of keratin with vimentin, desmin, or neurofilaments was seen in some tumors that were studied before and after radiation/chemotherapy, suggesting that the intermediate filament profile of tumor cells can be altered by external influences.

Coronary rheothermia: a quasi non-invasive method for controlling bypass patency

A method based on the principle of thermodilution was developed for a quasi non-invasive permeability control of aortocoronary bypass. An epivascularly-attached thermistor records the cooling of the bypass wall when, following the intravenous injection of 5 to 10 ml of a NaCl solution at 4 degrees C, a bolus of cooled blood passes through the bypass. During cardiosurgical intervention, the thermistor is attached to the venous bridge by one or 2 sutures. The efferent cable goes through the thorax wall and is coupled to a subcutaneously implanted telemetric amplifier unit. The influence of the vessel wall on the perivascular temperature signal, as compared to the intravascular one, was studied in acute and chronic animal experiments. In acute experiments the perivascular peak of temperature was found to be lower than the intravascular one. Continuous measurements over 9 days showed variations in the perivascular signals which must have been due to changes in the thermal capacity of the tissue coupled to the thermistor as well as to changes in resistance caused by a variable extent of scarred area and by the varying water content of the wound bed. These variables will continue to keep rheothermia within the limitations of a method with primarily binary results (= bypass: open or closed). Given stable coupling conditions after full development of the scar around the thermistor, the signal falsification by the then constantly coupled tissue capacity becomes calculable such as to obtain semiquantitative results which, theoretically should vary predominantly with cardiac output.

[Measurement of urethral closure pressure profiles with stress performed by CO2-infusion in stressincontinent women: sources of error in methodology and modes of clinical application (author's transl)]

The measurement of urethral closure pressure with stress is limited by the compressibility of gasiform mediums, which causes damping of intraurethral pressure spikes. In this study damping could be reduced by alterations of the catheter and the connecting tubes of an aircystometer. With this modified technique 55 incontinent women were examined. The differentiation between stress- and urgeincontinence was clinically sufficient.